Not all coverage is the right coverage.
Your healthcare coverage is important to us. Age, family status, medical conditions, hobbies, lifestyle and a myriad of other factors will help you determine if you need a lot or a very little amount of health coverage. This summary will help you understand your plan and its coverage.
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Summary Of Medical Benefits
Copay Plan
In-Network
Out-Of-Network
Calendar Year Deductible
Individual
Individual under Family
Family
$500
$1,000
$3,000
$6,000
Out-of-Pocket Maximum
$2,500
$5,000
$12,500
Preventive Care
No Charge
30%*
Office Visits
Primary Office Visit
Specialist Office Visit
Chiropractic Visit
$20 Copay
$40 Copay
Urgent Care Services
$50 Copay
Complex Imaging: MRI/CT/PET Scans
KIS Imaging
Non-KIS Imaging
10%*
Inpatient Hospital Care
Facility Fee
Physican Fee
$250 Copay, then 10%*
$500 Copay, then 30%*
Outpatient Procedures
Physician Fee
Emergency Services
Medical Transportation
$100 Copay
10%&
Mental Health/Chemical Dependency
Inpatient
Office Visit
Telemedicine Services Through Teladoc
General Consultations
Dermatology
Therapist
Psychiatrist, initial evaluation
Psychiatrist, ongoing session
Prescription Drug Coverage
Generic
Preferred Brand
Brand Non-Formulary
Specialty Drugs
Retail 30 Day Supply
$5 Copay
$15 Copay
$35 Copay
Mail Order 90 Day Supply
NOTE: * Coinsurance After Deductible
**Covered at in-network benefit level if determined medically necessary.
Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions
Dental Plan
Medical Deductible
$50
$150
Maximums
Deductible Year Maximum Benefit Per Person Age 19 and Over (Excluding Orthodontia)
Lifetime Maximum Benefit For Orthodontia (Coverage for participants up to age 26)
$1,500
Class I-Diagnostic and Preventive Procedures
Class II-Basic Procedures
15%*
Class III – Major Procedures
40%*
Class IV – Orthodontia
50%*
If you prefer talking with a HealthEZ representative, call 866-490-6171